A renewed focus on family medicine

Sunday

May 19, 2013 at 8:00 AM

By Priyanka Dayal McCluskey, TELEGRAM & GAZETTE STAFF

WORCESTER — For Elise M. Bognanno, the decision happened gradually.

She entered the University of Massachusetts Medical School not knowing what specialty she would choose. In her first year, she spent time shadowing a primary care physician, and she was struck by how well that doctor knew her patients.

Ms. Bognanno eventually realized she wanted to have long-term relationships with her patients, that she wanted to treat their whole families. She chose family medicine, one of 65 UMass students graduating this year who selected a primary care specialty.

It wasn't an easy decision, given that she knew she could earn more money specializing in a different field. She leaves school and starts her residency this year with $175,000 in student debt, to UMass as well as to the College of the Holy Cross, where she was an undergraduate.

"It's going to be difficult to get by," she said. "I can't imagine having more than that and trying to start a life. A lot of people are married; they're starting families right now, and it's really scary for them."

The enormous burden of student debt and the prospect of earning at the low end of the physician pay scale have discouraged many young doctors from choosing primary care — even though the country is facing a severe shortage of primary care physicians.

As the population grows and ages, the country will be short 52,000 primary care doctors by 2025, according to a widely cited study. Health insurance expansion will also put pressure on primary care providers.

Efforts to fill the gap are gaining momentum at medical schools across the country. At UMass Medical School, it's been happening for decades.

The need for primary care physicians was recognized many years ago, when UMass Medical was founded with the mission of producing more of them. Fifty-four percent of this year's graduates are joining residency programs in primary care — internal medicine, family medicine or pediatrics.

In a recent survey of older graduates, UMass found that half were still practicing primary care.

Nationally, about one-third of doctors practice primary care, while a smaller percentage of new doctors are choosing primary care over a specialty.

One draw at UMass Medical is that the school waives two-thirds of tuition — or $22,272 — for students who practice primary care for four years after graduation. Tuition and fees this year total $20,662.

UMass also encourages students to choose primary care by giving them early and frequent exposure to it, said Dr. Ronald N. Adler, an assistant professor at the medical school, and director of primary care practice improvement at a joint venture of the medical school and UMass Memorial Health Care.

Every student, in the first or second year of school, shadows a doctor at work in a clinic, as Ms. Bognanno did. Students are also paired with mentors, many of whom are primary care physicians.

"When students get into the office and they see the relationships we have with patients, they really like that," Dr. Adler said.

Primary care physicians fill many of the leadership roles at UMass, which sets a good example for students who feel primary care is not as prestigious as subspecialties like radiology or anesthesiology, he added.

At other medical schools, the exposure to primary care is not so positive.

Dr. Andrew Morris-Singer, president of the Cambridge nonprofit Primary Care Progress, said faculty at some schools explicitly discourage students from choosing primary care.

"They hear from doctors, 'Why would you have come to this medical school and go into primary care?' or, 'Hey, you seem really smart, don't go into primary care,' " Dr. Morris-Singer said.

He said the government should prod medical schools by tying federal money for residency positions and scientific research to the number of graduates going into primary care: "We need to attach strings to that money."

According to the Association of American Medical Colleges, 76 percent of schools had or were planning to start initiatives to encourage student interest in primary care. Many schools are expanding extracurricular opportunities or modifying clinical programs.

"In the last few years, there's been so much public emphasis on the need, that the number of initiatives to make primary are more attractive has increased," said Dr. Carol A. Aschenbrener, chief medical education officer of AAMC. "But it's not something medical schools can solve by themselves."

Primary care physicians earn roughly a third of what the highest-paid specialists make, losing $3.5 million in earnings on average over the course of their careers. A Medscape survey found family physicians earned about $175,000 on average last year.

The workload for primary care doctors can be heavy. They see new patients every 15 minutes, and after eight hours of patient visits, there is the paperwork.

Dr. David E. Weinstock, a primary care doctor at Grove Medical Center in Auburn, goes home every evening to play with his young children and have dinner with his family. But after that, he logs on to his computer and works for another two hours.

"It's not uncommon at the end of the day to have 100-plus labs to look through, to have 30 phone calls," he said. "Every time you turn the computer on, there's more stuff waiting for you. Depending on what your family life is like, you can get burned out by doing it if you're not careful."

And primary care doctors are not paid for much of the time they spend working on the phone and the computer. Dr. Adler, who practices at Hahnemann Family Health Center in Worcester, recently sent one patient for a colonoscopy; the test detected cancer. Dr. Adler spent time emailing and calling his patient's other doctors — the gastroenterologist, the colorectal surgeon, the oncologist.

"I'm sort of the glue that holds that together," he said, "but I don't get paid for that."

This may change as payers, both public and private, move away from the fee-for-service payment model that reimburses doctors for the services they perform, instead of the time they spend on preventive care and care coordination.

More than half of the patients who have Fallon Community Health Plan are part of "risk-based relationship" models, in which physicians are paid for keeping patients healthy, instead of the traditional fee-for-service model. More doctors' groups have been switching to these types of models, said Dr. Elizabeth C. Malko, the outgoing executive vice president and chief medical officer at Worcester-based Fallon.

But, she said, "The fundamental change really needs to occur at the national level."

The Centers for Medicare & Medicaid Services has been urging providers to experiment with new models.

At UMass Medical School, Dr. Michael F. Collins, the chancellor, warned that the doctor reimbursement pie is not getting any bigger. He said cities, towns and provider groups could make primary care more attractive by offering scholarships or loan forgiveness programs to new recruits.

Dr. Aschenbrener of AAMC said the problem entails more than money; it's about the value of the work primary care doctors do, the work of building relationships, she said.

"We live in a society that glamorizes technology and action and materialism and puts less attention to relationships," she said. "We need to think about what we value in this country."